Headlines about "Medicare and Medicaid"

Gathered from the web by the editors at BenefitsLink.com.
Effects of Prescription Drug Insurance on Hospitalization and Mortality: Evidence from Medicare Part D
"[O]btaining prescription drug insurance through Medicare Part D was associated with an 8% decrease in the number of hospital admissions, a 7% decrease in Medicare expenditures, and a 12% decrease in total resource use. Gaining prescription drug insurance through Medicare Part D was not significantly associated with mortality." (National Bureau of Economic Research [NBER]; purchase required)

CMS: Engaging Multiple Payers in Payment Reform
"CMS is testing more than 20 models under this authority that create new incentives for clinicians and organizations that deliver medical care through CMS programs to deliver better care at lower cost. CMS is also supporting a variety of state efforts to create new incentives for these clinicians and organizations through the Medicaid and CHIP programs. All of these models share a common pathway for success: they hinge on getting clinicians and health care organizations to manage the health of populations and to act as good stewards of health care resources." (JAMA)

Report on CMS Collection and Use of ACA Annual Fee on Branded Prescription Drug Companies
"Although the funds from the annual fee are allocated to the [Medicare] Part B Trust Fund, the ACA grants to Treasury the responsibility of administering the fee process, including transferring the fee to the Trust Fund. To the extent that the fees were not in the Trust Fund, the Trust Fund may have missed an opportunity to earn interest income on these fees. Our results indicate that it may be beneficial for CMS to periodically monitor the status of this fee in the Trust Fund, and to contact Treasury if CMS finds that the full amount to be collected under the ACA each year has not been received." (Office of Inspector General, Department of Health and Human Services)

Governor Details Healthcare Payment Reform Path in Arkansas
"Arkansas is among several states that have decided to expand Medicaid through a 'private option,' using the 100 percent federal expansion financing to fund private insurance policies for the poor purchased through the state's PPACA exchange[.]" (HealthLeaders Media)

[Official Guidance] HHS OIG Advisory Opinion 14-04 on Medigap Premium Credits Provided for Policyholder Use of Preferred Network Hospitals (PDF)
"We are writing in response to your request for an advisory opinion regarding the use of a 'preferred hospital' network as part of Medicare Supplemental Health Insurance (Medigap) policies, whereby [name redacted] would indirectly contract with hospitals for discounts on the otherwise-applicable Medicare inpatient deductibles for its policyholders and, in turn, would provide a premium credit of $100 to policyholders who use a network hospital for an inpatient stays.... Although the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of Federal health care program business were present, the [OIG] would not impose administrative sanctions on [name redacted] under sections 1128(b)(7) or 1128A(a)(7) of the Act (as those sections relate to the commission of acts described in section 1128B(b) of the Act) in connection with the Proposed Arrangement. In addition, the OIG would not impose administrative sanctions on [name redacted] under section 1128A(a)(5) of the Act in connection with the Proposed Arrangement." (Office of Inspector General, Department of Health and Human Services)

[Guidance Overview] CMS Issues Medicare Part D Benefit Parameters for 2015
"These parameters will be used by group health plan sponsors to determine whether their plans' prescription drug coverage is creditable for 2015. The information is needed for the disclosures that must be made annually and at other specified times to Part D eligible individuals and to CMS." (Thomson Reuters / EBIA)

Doctors React to Release of Medicare Billing Records
"Doctors reacted swiftly and indignantly to Wednesday's release of government records revealing unprecedented details about Medicare payments to physicians.... [M]any of the doctors said they were just passing through the payment to drug companies. Some said they were unfairly singled out even though they were billing for an entire practice. And still others disputed the accuracy of Medicare data." (The Washington Post; subscription may be required)

Medicare Reveals How Much It Pays Each Doctor -- Here's What the Data Show
"[T]he released data show that Medicare paid $12 billion for about 214 million office and outpatient visits in 2012. Most providers received relatively modest Medicare payouts ... However, about 2% of physicians and other individual providers accounted for almost one-quarter of the $77 billion total. And about one-quarter of providers participating in Medicare receive about three-quarters of the total payments." (The Advisory Board Company)

U.S. Insurers Still Expect Cuts in 2015 Medicare Payments
"U.S. health insurers said on Tuesday they still expected cuts in government reimbursements for privately managed Medicare health plans for the elderly next year even after the Obama administration rolled back the steepest reductions. The government agency that oversees Medicare said late on Monday that on average, reimbursements to insurers for private Medicare plans would rise 0.4 percent, reversing what it said was a proposed cut of 1.9 percent." (Reuters)

[Opinion] Hooray! The Medicare Doc Fix is Fixed Until Next April!
"According to the [CBO's] score of the bill, it increases Medicare's physician payments by $15.8 billion over ten years. However, $11.2 billion (71 percent) is spent by 2015, and $13.3 billion (84 percent) is spent by 2016. The savings to pay for this? Those come later, much later: Savings don't become greater than spending until 2020, and not significant until 2024 -- the last year of the mandated scoring 'window', when the law is supposed to claw back $9.3 billion from hospitals and re-impose the sequester on Medicare." (John Goodman's Health Policy Blog)

[Official Guidance] HHS Announces Medicare Enrollments Now Available for People in Same-Sex Marriages
"[HHS has] announced that the Social Security Administration (SSA) is now able to process requests for Medicare Part A and Part B Special Enrollment Periods, and reductions in Part B and premium Part A late enrollment penalties for certain eligible people in same-sex marriages." (U.S. Department of Health and Human Services)

Why Some Don't Pay Their Obamacare Premium: It's Not What You Think
"Researchers at the U.C. Berkeley Labor Center released estimates Wednesday showing that about 20 percent of Covered California enrollees are expected to leave the program because they found a job that offers health insurance. Another 20 percent will see their incomes fall and become eligible for Medi-Cal, the state's insurance program for people who are low income. In addition to the 40 percent of enrollees who move to Medi-Cal or job-based insurance, between 2 and 8 percent of those who sign up for Covered California are estimated to become uninsured, the analysis noted." (Kaiser Health News)

Congress Delays Medicare Cuts until 2015
"On March 31, the Senate voted to pass yet another 'doc fix' bill, which had been approved by the House the week before.... It comes at the 11th hour, as the SGR ... would have meant a sharp 23.7% drop in Medicare payments just hours later on April 1.... This latest doc fix ... again temporarily delays the looming cuts in Medicare payments, replacing the 24% cut with a 0.5% payment update through the rest of 2014 ... Congress is still working on a full repeal of the SGR." (Sheppard Mullin)

Draft Rules Would Help Protect Seniors When Medicare Advantage Plans Drop Doctors
"The proposals follow UnitedHealthcare's decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.... Officials say that the terminations only a few weeks before Medicare's Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers. The proposals would give beneficiaries more than 30 days' advance notice of network changes and providers at least 60 days' advance notice of a contract termination." (Kaiser Health News)

Understanding Health Insurance Options in Retirement (PDF)
"This paper is intended to provide a backdrop of the current health insurance landscape for retirees. Specifically, this paper gives a broad overview of the Medicare system and provides retirees with information which may help them understand their health insurance options in retirement. Furthermore, this paper includes information on the magnitude of potential health care-related costs throughout retirement." (Manning & Napier)

A Better Way to Cut Medicare Spending
"The reform consists of two changes to current law: [1] raising the Medicare eligibility age to the same age as Social Security (and thereafter indexing it to increases in longevity) and [2] requiring higher income seniors to pay a greater share of their medical costs (or so-called means testing). This reform ensures that low income workers receive full benefits (defined as the average benefits retirees would receive if the ACA's cost-cutting provisions are not realized) upon attaining the new eligibility age." (John Goodman's Health Policy Blog)

Framing Medicare Reform (PDF)
"Social Security and Medicare provide for a large share of many retirees' consumption and thus reduce the amount of savings necessary for their retirement years. The degree to which the combined programs replace preretirement compensation has been rising for successive groups of new retirees, and consequently their required savings rate is lower. This analysis contrasts the replacement rates under two forecasts: the baseline, or current law, forecast presented in the 2013 Medicare Trustees Report and the Trustees Report's alternative forecast.... Should spending continue to grow at the rates underlying the alternative forecasts, Medicare's insurance value, once premiums are netted out, grows as a percent of retirees' preretirement average compensation." (Private Enterprise Research Center, Texas A&M University; via National Center for Policy Analysis)

ML Strategies Health Care Update, March 17, 2014 (PDF)
Topics include: [1] SGR fix advances in the House, action planned in Senate; [2] Senate presses HHS for details on budget following House testimony; and [3] House lawmakers warn against Medicare Advantage cut. (ML Strategies, LLC)

Can Congress Put an End to Annual Medicare Payment Ritual?
"Congress is still searching for money to avoid a 24 percent cut in pay for doctors who treat Medicare patients. But seniors are already paying their share of the cost in premiums, as if the pay cut -- scheduled to kick in on April 1 -- won't happen.... Instead of replacing the formula as enacted, Congress is likely to delay the cut until the end of the year, when they will face the same dilemma again. In addition to the anxiety this annual ritual provokes in many patients and their doctors, a premium subsidy for some low-income Medicare beneficiaries is also in jeopardy." (Kaiser Health News)

CMS Puts Bulk of Part D Proposed Rule on Hold
"While the proposed rule is on hold for now, CMS said it plans to 'engage in further stakeholder input before advancing some or all of the changes in these areas in future years.' As of March 7, the final day for comments, CMS had acknowledged receiving about 5,800 comments on its proposed rule, most of which were in opposition." (HighRoads)

Proposed Medicare Part D Drug Changes Are Scrapped
"Marilyn Tavenner, the Medicare agency administrator, said the drug-coverage provision and some other proposed changes to pharmacy networks and drug plans would be shelved for now. Ms. Tavenner said the agency would 'engage in further stakeholder input before advancing some or all of the changes in future years.' She added that the agency planned to proceed with other proposals in its January document related to consumer protections and antifraud provisions that have bipartisan support." (The Wall Street Journal; subscription may be required)

New Hampshire Medicaid Expansion Will Include Subsidies for Employer-Provided Coverage
"[T]he New Hampshire Senate on Thursday voted to expand Medicaid to cover as many as 50,000 low-income residents using tens of millions of dollars in federal aid. About 12,000 residents who would qualify for coverage would be given subsidies to pay for insurance through their employers. Thousands more would receive subsidies to buy private insurance through the state's health-care exchange." (The Washington Post; subscription may be required)

Proposed Legislation Ties Individual Mandate to Doctor Fee Fix
"The House will vote next week on legislation to delay ObamaCare's individual mandate and prevent a cut in Medicare payments to doctors. Republicans are putting the two bills together so that revenue generated by delaying the individual mandate could be used to pay for preventing a cut in doctor payments.... While the individual mandate would bring in revenue in the form of fines from people who don't sign up for a health plan, past scores have said implementing the mandate actually costs $9 billion a year. A House GOP aide said the proposed language would be a delay of the individual mandate for several years, but probably less than 10." (The Hill)

Effects of Prescription Drug Insurance on Hospitalization and Mortality: Evidence from Medicare Part D
"Results indicate that obtaining prescription drug insurance through Medicare Part D was associated with an 8% decrease in the number of hospital admissions, a 7% decrease in Medicare expenditures, and a 12% decrease in total resource use. Gaining prescription drug insurance through Medicare Part D was not significantly associated with mortality." (National Bureau of Economic Research [NBER])

More Than 200 Groups Urge CMS to Withdraw Proposal on Part D Benefit
"Proposed changes to Medicare's prescription drug program would negatively affect beneficiaries and the companies that serve them and should be withdrawn, more than 200 groups told [CMS] in a Feb. 18 letter.... The 236 organizations included health plans and various consumer and medical groups, such as Easter Seals, America's Health Insurance Plans, Blue Cross and Blue Shield Association, American Osteopathic Association and the Pharmaceutical Care Management Association." (Bloomberg BNA)

Humana Leads Insurer Gains on Proposed Medicare Payments
"Health insurers who run Medicare Advantage, the private version of the government's managed-care program for the elderly and disabled, face a base payment cut of about 3.55 percent next year, the U.S. government said on Feb. 21. Humana [on Feb. 24] estimated the final reduction will be 3.5 percent to 4 percent, a smaller decline than the ... company's previous estimate of 6 to 7 percent." (Bloomberg)

[Guidance Overview] Medicaid Asset Rules and the ACA
"[CMS recently] released a State Medicaid Directors Letter analyzing the application of Medicaid liens, estate recoveries, transfer-of-asset rules, and post-eligibility income rules to individuals who become eligible for Medicaid because of their modified-adjusted gross income (MAGI).... Although the federal and state law governing Medicaid liens and estate recoveries are primarily concerned with recipients who receive high-cost long-term care services, federal law that existed prior to the ACA allows states to recover from the estates of any Medicaid recipient age 55 or over for the cost of any Medicaid services, and a number of states have existing laws that would allow such recoveries. ACA opponents have been spreading the word that if people age 55 or over sign up for expansion Medicaid, the government will recover from their estate when they die. The Memorandum attempts to address these concerns." (Timothy Jost in Health Affairs Blog)

Government Proposes Cuts to Insurers' Medicare Payments
"[One analyst] calculated the overall rate cut at around 7.8%, compared with her projection of between 6% and 7%, not including an industry fee levied under the health-care law.... The Friday proposal pegged a key measure of Medicare cost growth even lower than the industry had predicted -- at -3.55%, compared with -1.98% in a report commissioned by America's Health Insurance Plans[.]" (The Wall Street Journal; subscription may be required)

Medicare Reimbursement Cuts Kill
"Under the Balanced Budget Amendment of 1997, different classes of hospitals received different cuts in Medicare reimbursement. The cuts reduced Medicare inpatient payment by an estimated 5 percent between 1998 and 2000. By contrast, the [ACA] will reduce DRG payments by 1.1 percent per year indefinitely. A 2013 article ... examines the effect of the BBA reimbursement rate cuts on risk-adjusted mortality rates 7, 30, 90, and 365 days after hospital admission. [The authors] find that the risk of dying increases with the size of Medicare reimbursement cuts." (John Goodman's Health Policy Blog)

[Opinion] Health Spending on State and Local Government Workers Has Outpaced Medicaid Spending by Almost 20 Percent
"[R]esearchers conclude that state and local spending on government workers increased by 444 percent in real, inflation-adjusted terms from 1987 through 2012. Spending on Medicaid grew by 375 percent.... How do government workers get away with it? Because health benefits are a defined benefit, rather than a defined contribution, their future costs are not properly reflected in the current fiscal year's cashflow." (John Goodman's Health Policy Blog)

[Guidance Overview] Deadline Nears For Submission of Creditable Coverage Disclosures to CMS
"A plan sponsor must submit a new disclosure to CMS no later than 60 days after the beginning of each plan year -- i.e., by March 1, 2014 for calendar year plans.... In preparing the disclosure to CMS, plan sponsors need to: [1] Identify the number of prescription drug options the plan offers to Medicare eligible individuals. [2] Determine the number of benefit options offered that are creditable coverage vs. non-creditable. [3] Estimate the total number of Medicare eligible individuals expected to have coverage under the plan at the start of the plan year. This includes any health plan enrollees who are Medicare eligible active employees, COBRA enrollees, retirees, or disabled individuals and any of their Medicare-eligible dependents." (Marsh Consulting Group)

GAO Report on Demographics and Service Usage of Certain High-Expenditure Medicaid Beneficiaries
"In fiscal year 2009, states spent nearly a third (31.6 percent) of all Medicaid expenditures on the most expensive Medicaid-only beneficiaries, who were 4.3 percent of total Medicaid beneficiaries. States spent another third (33.1 percent) on all other Medicaid-only beneficiaries, who represented 81.2 percent of total Medicaid beneficiaries.... Overall, hospital services and long-term services and supports in non-institutional and institutional settings comprised nearly 65 percent of the total expenditures for high-expenditure Medicaid-only beneficiaries ... payments to managed care organizations and premium assistance comprised 57.2 percent of total expenditures for all other Medicaid-only beneficiaries." (U.S. Government Accountability Office)

Breast Cancer and Government Coverage Versus Private Health Insurance
"Covering all breast cancer cases registered from 1996 to 2005, the data once again suggest that the uninsured fare almost as well as people on Medicaid.... Several interpretations are possible. One is that the health behaviors of those on Medicaid differ in important, and poorly considered, ways from the health behaviors of those with private insurance. Another is that these results are roughly similar for people on Medicaid and those who are uninsured because during the time covered by the study, people in the United States with serious illness could access health care whether or not they had coverage." (John Goodman's Health Policy Blog)

[Opinion] Can the 'Better Care, Lower Cost Act' Live Up to Its Name?
"Last month, Senators Wyden, Isakson, Welch, and Paulsen introduced an ambitious bill for Medicare reform.... [T]he bipartisan proposal aims to shift the program away from fee-for-service by amplifying the ACO model.... The text of the new bill seems to emphasize a role for telemedicine and remote patient monitoring, but the most successful programs identified by the CBO -- which still didn't achieve net savings for Medicare -- employed significant in-person interaction between patients and physicians or care managers. Initiatives that relied primarily on telephone interaction had little to no effect on spending or hospital admissions, on average." (The Incidental Economist)

ACA Health Insurer Fee: Estimated Impact on State Medicaid Programs & Medicaid Health Plans, January 2014 Update
"[T]he Medicaid managed care portion of the insurer tax will cost the Medicaid program about $37.7 billion over a ten year period starting in 2014. The state government portion of this will be $13.6 billion and the federal government portion will be $24.1 billion. About one-sixth of the total tax will be paid by Medicaid managed care plans. However, the Balanced Budget Act of 1997 put in place federal actuarial soundness requirements mandating that states must pay Medicaid health plans actuarially sound rates which adequately cover medical costs, administration, taxes & fees. This means that the government will actually be required to fund the entire insurer tax." (Medicaid Health Plans of America)

CBO Says Premium Support Works
"The CBO finds that, in a new competitive system of health plans, private plans can offer the same benefit and services as traditional Medicare fee-for-service (FFS) plans -- at a lower cost to taxpayers. Moreover, depending on the competitive bids among plans and the payment structure, the report also reveals that competition can drive lower beneficiaries' premiums and out-of-pocket expenses would decline." (John Goodman's Health Policy Blog)

[Opinion] Text of American Benefits Council Letter Asking CMS to Keep Medicare Advantage Rates Flat in 2015 (PDF)
In 2014, Medicare Advantage rates were reduced by 6.7 percent. We understand that additional significant rate cuts are under consideration for 2015. We are concerned that further rate reductions could detrimentally affect retirees in the form of higher out-of-pocket costs, less coverage and fewer provider options for retirees. To avoid this result, we respectfully request that rates remain flat for 2015." (America's Health Insurance Plans [AHIP])

New 3.8% Investment Tax Raises Flags
"Congress enacted the 3.8% surtax on dividends, interest and other income back in 2010, but didn't make it effective until tax year 2013. Even though advisers have been studying the tax's rules, many still have some questions as they help clients report the tax for the first time.... Tax experts want more direction from the Internal Revenue Service on how to report retirement income and calculate write-offs for state and local taxes and certain expenses that are also subject to the tax." (The Wall Street Journal; subscription may be required)

[Opinion] Congress Finally Produces Plan to Overhaul Doctor Payments
"What Congress wants to do differently this time around is, by 2021, put as much as nine percent of doctors' reimbursements at stake if providers can't hit certain quality standards. It would also include a bonus pool of $500 million for the doctors who do provide really great care. The idea is to use metrics, such as whether they're adopting electronic medical records and hitting certain medical quality targets, to adjust upward or downward what doctors' earn. That's quite different from the current, largely fee-for-service system, where doctors get a flat fee regardless of whether their patients get any better." (Sarah Kliff in The Washington Post; subscription may be required)

Early Indications of Changes to the 2015 Medicare Advantage Payment Methodology and the Potential Effect on Medicare Advantage Organizations and Beneficiaries (PDF)
13 pages. Excerpt: "[T]he potential reductions that could be included in the 2015 Advance Notice, in combination with the continued phase-in of the ACA cuts and other legislative and regulatory cuts which come on top of significant cuts that occurred in 2014 ... could result in a significant amount of upheaval in the [Medicare Advantage (MA)] market. This includes the potential for plan exits, reductions in service areas, reduced benefits, provider network changes, and reduced MA enrollment as beneficiaries see a significant decline in plan value from 2014 to 2015." (Oliver Wyman, for America's Health Insurance Plans [AHIP])

Proposed Bipartisan Bill Would Reward Medicare Doctors for Quality
"After negotiating for months over how to overhaul Medicare's troubled payment system for physicians, the bipartisan leadership of three Senate and House committees has reached a deal on the policy.... [D]octors would receive an 0.5 percent bump for each of the next five years as Medicare transitions to a payment system designed to reward physicians based on the quality of care provided, rather than the quantity, as the current payment formula does." (Kaiser Health News)

Repealing and Replacing the Sustainable Growth Rate: a Fact Sheet
"Since 2003, Congress has spent nearly $150 billion in short term patches to avoid unsustainable cuts imposed by the flawed SGR. The most recent patch will expire on March 31st. Building on bipartisan legislation unanimously reported out of the House Energy & Commerce and Ways & Means Committees, and reported out of the Senate Finance Committee, the unified legislation from the three committees repeals the SGR and transitions Medicare away from a volume-based system towards one based on value." (House Committee on Energy and Commerce)

Patients Need Training on New Health Insurance
"New Medicaid patients in Oregon failed to use their benefits effectively because they did not understand how to use insurance or health care ... People assumed if they used their insurance for something minor, like a physical, someone who needed care more might not get a turn.... Patients who knew they only had emergency dental care assumed that extended to all health care, so they went to the emergency room and not a regular doctor's office. Medicaid beneficiaries did not understand that preventive screenings could save the system money in the long term, or simply didn't know they should get an annual exam. People were afraid of how much they would be required to pay if they saw a doctor." (USA TODAY)

Pioneer ACOs' First-Year Results Leave a Lot of Room for Improvement
"Altogether, the Pioneers produced savings of about $147 million, a drop in the bucket for the entire Medicare budget, and certainly much less than the amount spent to develop the infrastructure to support the ACOs. Officials with [CMS] -- which is managing the Pioneer and the Medicare Shared Savings Program (MSSP) ACOs -- said some progress is better than none, and the program will take time to produce more significant savings." (HealthLeaders InterStudy)

Use of Telemedicine Can Reduce Hospitalizations of Nursing Home Residents and Generate Savings for Medicare
"After the introduction of the telemedicine service, hospitalization rates declined 9.7 percent among the intervention facilities and 5.3 percent among the comparison facilities ... There was a significant decline in hospitalization rates at facilities that were deemed 'more engaged' with the telemedicine service; hospitalization rates for this group declined 11.3 percent. Based on the reduced hospitalization rates of the more-engaged facilities, Medicare could expect an average of about $151,000 in savings per nursing home per year. The annual cost of the telemedicine service was $30,000 per nursing home, suggesting that there could be $120,000 in net savings per year." (The Commonwealth Fund)

[Official Guidance] Text of CMS FAQs on the Sale of Individual Market Policies to Medicare Beneficiaries Under 65 Losing Coverage Due to High Risk Pool Closure (PDF)
The unnumbered document is dated January 31, 2014. Excerpt: "May an issuer request documentation from an applicant or enrollee to establish that the individual falls within the scope of this bulletin? ... When can Medicare beneficiaries enroll in individual market plans pursuant to the bulletin? ... When can Medicare beneficiaries enroll in Medicare Advantage or Prescription Drug plans? ... Can these Medicare beneficiaries who enroll in individual market plans pursuant to the bulletin receive a tax credit under Code section 36B? ... How will coordination of benefits occur between Medicare and the individual market plan issuer in these circumstances? ... Are issuers required to sell individual market coverage to Medicare beneficiaries in this specific circumstance?" (Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services)

[Opinion] Why the SGR Fix Won't Work and Could Actually Make Things Worse
"The SGR fix would basically freeze or severely limit future physician fee updates for Medicare Part B (a serious problem for primary care), while permitting physicians to earn modest 'value-based' bonuses if they can document quality measure attainment, cost reductions, participation in alternative payment schemes, practice enhancement activities, or meaningful use of EHRs.... With this legislation, Congress is preparing yet again to enshrine in statute another payment strategy that is both unproven and highly controversial." (The Health Care Blog)

[Opinion] Imposing Limits to First-Dollar Coverage Would Increase Cost-Sharing for Medigap Policyholders
"Adding a new tax on Medigap would increase costs for vulnerable beneficiaries who rely on the predictability and financial protection Medigap provides. In addition, proposals that would limit first-dollar coverage in Medigap policies 'would cause the most harm to those beneficiaries who have the greatest need for coverage, the sickest individuals and people with low and modest incomes' ... This finding echoes stakeholders' concerns regarding proposals that would prohibit Medigap first dollar coverage[.]" (America's Health Insurance Plans [AHIP])

Income Subject to Payroll Tax Increases in 2014; FICA Withholding Needed
"By Jan. 1, U.S. employers should have: [1] Adjusted their payroll systems to account for the higher taxable maximum under the Social Security portion of FICA. [2] Notified affected employees that more of their paychecks will be subject to FICA." (Society for Human Resource Management)

What Health Insurance Coverage Changes Are the Uninsured Anticipating for 2014?
"Almost one in five (17.6 percent) of all nonelderly adults were uninsured on the eve of reform. Overall, 39.3 percent of these adults expected to gain health insurance coverage in 2014. Younger, nonwhite or Hispanic, and healthier adults were more likely to expect to gain coverage ... Nearly a third (31.0 percent) of the adult Medicaid target population thought they would be eligible for Medicaid in 2014." (Urban Institute)

CBO Cost Estimate for H.R. 2810, 'SGR Repeal and Medicare Beneficiary Access Act of 2013'
"H.R. 2810 would replace the Sustainable Growth Rate (SGR) formula, which determines the annual updates to payment rates for physician services in Medicare, with new systems for establishing those payment rates. CBO estimates that enacting H.R. 2810 would increase direct spending by about $121 billion over the 2014-2023 period. (The legislation would not affect federal revenues.)" (Congressional Budget Office)

Trying to Count Obamacare's Medicaid Enrollment? Good Luck.
"Using Arkansas numbers, Sean Trende has estimated that about 45 percent of those signing up for Medicaid are newly eligible under the health-care law. Taken together, these numbers seem to suggest about one-third to half of the Medicaid sign-ups are among those newly-eligible under Obamacare. But again, we won't know the actual number until April at the earliest." (Sarah Kliff in The Washington Post; subscription may be required)

[Guidance Overview] CMS Proposes Major Changes to Medicare Parts C and D
"If adopted as drafted, these rules will significantly impact how Medicare Advantage (MA) organizations and Part D Prescription Drug Plan (PDP) sponsors operate and interact with their contractors, beneficiaries, and the government. The proposed rules will also impact the operations of all health care entities involved in providing drug products under Parts C and D, including pharmacy benefit managers (PBMs), pharmacies, physicians, and pharmaceutical manufacturers. Impacted parties and entities will want to carefully review the text of the proposed rules, along with CMS's justification for the rules, and consider submitting comments by the deadline." (Mintz Levin)

[Guidance Overview] CMS Proposed Rule Reflects Increased Sophistication in Administration of Medicare Advantage and Part D Programs
"Addressing issues ranging from participation in Part D Plan pharmacy networks to compliance training for so-called first-tier, downstream and related entities, the Proposed Rule covers numerous topics with varying degrees of importance for MA Organizations, Part D Plan Sponsors, pharmacy benefit managers, and other health care and administrative service providers participating in the Programs. This summary of the Proposed Rule addresses several issues of interest for both MA Organization and Part D Plan Sponsors (collectively, Plan Sponsors), as well as for entities with which Plan Sponsors contract." (McDermott Will & Emery)

The Times They Are a Changin' -- or Should We Say 'Churning?'
"This coming year will be the proving ground for this new definition of churning and its impact on low-income Americans as they try navigate a changing health care landscape. Those who fail to stay on top of their eligibility could fall into coverage gaps, run the risk of having to pay back the federal government for subsidies used when they were not eligible, or both." (ExtendHealth)

Continuous Insurance Before Medicare Enrollment Associated with Better Health and Lower Program Spending
"Beneficiaries with continuous health insurance coverage for approximately 6 years before enrolling in Medicare were more likely than those without prior continuous insurance to report being in good health or better during the first 6 years in Medicare. In particular, having prior continuous insurance raised the predicted probability that a beneficiary reported being in good health or better by nearly 6 percentage points during the first 6 years in Medicare. Beneficiaries with prior continuous insurance had lower total program spending during the first year in Medicare compared with those without prior continuous insurance." (U.S. Government Accountability Office)

Medicare Physician Payment Reform: Will 2014 See the Fix for SGR?
"Physicians can receive bonuses of up to 5% per year from 2017 to 2022 for transitioning to 'alternative payment models' in which payments are increasingly related to value defined as measured quality and total cost of care.... How much physician payment reform occurs in 2014 may come down to how much physicians are willing to advocate for alternatives to the predictable but consuming short-term patches -- alternatives that may not be permanent or clear but that would give physicians much more opportunity to lead in reforming health care." (JAMA)

CMS Modifies Policy on Disclosure of Physician Payment Information
"Going forward, CMS will evaluate requests for individual physician payment information (or requests for information that combined with other publicly available information could be used to determine total Medicare payments to a physician) on a case-by-case basis.... In addition, CMS will generate and make available aggregate data sets regarding Medicare physician services for public consumption." (Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services)

[Official Guidance] Text of CMS Notice on Change in Policy for Disclosure of Amounts Paid to Individual Physicians under the Medicare Program
"The Secretary has considered the court's decision [to vacate its injunction prohibiting disclosure] and the wide spectrum of public comments received by CMS.... [HHS] has decided to replace the prior policy, as set forth in the November 28, 1980 Federal Register ... with a new policy in which CMS will make case-by-case determinations as to whether exemption 6 of the Freedom of Information Act applies to a given request for information pertaining to the amounts that were paid to individual physicians under Medicare." (U.S. Department of Health and Human Services)

Principles for Designing Consumer-Friendly Wellness Programs in Medicaid (PDF)
"This brief introduces the concept of wellness incentive programs, and it lays out the key elements that a Medicaid wellness incentive program should have to protect enrollees' access to care and help them make healthy behavior changes. It also discusses options consumer advocates can suggest if their state proposes a penalty-based wellness program that could harm enrollees' access to care." (Families USA)


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